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One of the most important life skills that CBT therapists promote to their clients is how to communicate effectively. Building and reinforcing good communication skills is associated with better organization of thoughts and improved connectedness with others, and it also aids the therapeutic process itself. This much is true regardless of the client’s presenting problems, but it is especially so in cases of clients whose difficulties include disruptions of self-regulation, as we often see in bipolar spectrum disorders (Newman, Leahy, Beck, Reilly-Harrington, & Gyulai, 2001).
The challenges that such clients face may be trait-based — meaning that their fund of knowledge about how to express themselves appropriately and accurately is limited by dint of their suboptimal learning experiences, and/or state-based – such as when the clients’ communications are over-restricted due to a depressive episode, or conversely under-controlled in the context of a mixed state, hypomanic episode, or a full-blown manic episode.
This blog will briefly address the latter problem, i.e., helping clients with their state-based communication, regardless of their symptom episodes, mainly by helping the clients to become more self-aware and better self-managers of the words they utter and type. Further, as will be noted below, the manner in which clients with bipolar disorder communicate may serve as a valuable early warning sign of prodromes, identification of which may allow the client and therapist to take prompt steps to address and limit the progression of the symptom episode.
One of the hallmarks of CBT is its emphasis on helping clients to moderate their otherwise extreme thoughts, feelings, and actions. CBT practitioners help clients see the benefits of finding the proverbial “happy medium.” This principle is highly applicable to persons with bipolar illness in general, such as in helping them to keep their manner of communicating “within normal limits.” How do we do this? First, we seek to understand. As CBT clinicians it is vital that we try to see things through the clients’ eyes, and to demonstrate empathy for the clients’ current state of mind even as we try to help them make changes.
For example, we give them feedback that validates how difficult and pointless it may seem (in the clients’ view) to respond to other people’s communications when the clients are experiencing crushing dysphoria. Similarly, we acknowledge how challenging it can be to restrain oneself from sharing every thought with every ounce of energy when the client is euphoric and/or agitated (e.g., with concomitant anxiety). Next, we help our clients learn to utilize compassionate self-awareness, including applying self-instruction (in contrast to self-reproach and self-punishment) about how to communicate. Examples of self-instructions (which can be written down for easy access) that clients can employ when in a depressive, withdrawn state include:
- “Just send an acknowledgement. Be kind and respectful to [the other person]. Sometimes I can help myself feel a little better just by doing something nice for others.”
- “If I respond to [the other person], I will succeed in doing an exposure and a behavioral experiment, and good things may actually happen if I keep an open mind.”
- “I don’t have to have exactly the right words. Making a good faith effort to communicate is admirable, and most reasonable people will appreciate my effort.”
Examples of self-instructions that clients who are experiencing hypomanic, mania, or mixed (agitated) states may apply include:
- “Let [the other person] get a word in. Be a good listener. Be receptive.”
- “Wait before [texting, e-mailing, calling] back. Give [the other person] some space.”
- “I will write down my thoughts and feelings, but I will wait until later or tomorrow to decide if should share them.”
Quite literally, the ways in which clients communicate with others send messages about their state of mind, their self-awareness, their level of consideration for others, and how pleasant or unpleasant it will be for the other person to engage. As clinicians, we want to help our clients to build and maintain a healthy support system. Helping them to communicate appropriately is central to this goal (see Miklowitz, 2008).
One way we can work toward a favorable outcome is to give the clients clear, caring, instructive feedback about their communications in the therapeutic relationship. For example, when a client is demonstrating pressured speech in session, the therapist can put up a hand and say, “Let’s take a moment to breathe slowly, and then let’s take turns talking.”
Similarly, if the client is sending the therapist a stream of messages between sessions, the therapist can reply with one, concise, polite message that says, “Together, we will do our best to address your concerns in our next session. Feel free to write down your thoughts if you want to make sure you remember them, and you can use those notes when we meet.”
CBT practitioners often help their clients to find “a healthy middle ground” of thoughts, emotions, and behaviors, and this includes striving to set standards for moderate rates and tones of communicating – neither under-communicating nor over-communicating, and keeping the substance and tenor of the communication respectful and constructive. The therapeutic relationship is an excellent vehicle through which to help clients with bipolar disorder practice this approach to communicating with others.
CBT practitioners can offer their clients some specific guidelines about managing their communications, any of which can be discussed collaboratively prior to implementing. Clients’ additional ideas are welcome for further consideration as well, as they are active participants in the skill-building and self-management process. Guidelines may include:
- Reduce the use of extreme words and speak your mind without using any profanity.
- Rather than sending long or frequent text messages (which can be intrusive), handwrite what you would like to say, then put it aside, then decide later if you want to send it in an e-mail that the other person will view when they choose.
- If someone is worried about you, state a brief, pleasant acknowledgement, even if you are not up for a full conversation.
- If you have something serious to say, say it solemnly rather than loudly and/or angrily.
- If you are very eager to hear from someone, give them a reasonable chance to respond to your first message before sending more messages.
A key self-monitoring skill that CBT therapists help their clients with bipolar disorder develop is the ability to recognize early warning signs of symptom episodes, and then to take remedial steps to mitigate the scope and impact of the impending episode. A number of major clinical trials have found that this area of improvement is one of the most important elements of the CBT package for bipolar disorder (e.g., Lam, Hayward, Watkins, Wright, & Sham, 2005; Perry, Tarrier, Morriss, McCarty, & Limb, 1999; Scott et al., 2006).
Apropos of this discussion, one of the chief warning signs is a problematic change in the ways that bipolar clients communicate. In a depressive phase, clients are prone to withdraw, manifested in part in an absence of responsiveness when others try to reach out to them via phone, e-mail, or text. In a hypomanic state (and/or oncoming manic state), clients will demonstrate flights of ideas, pressured speech, and a tendency to “over-communicate,” which means that the clients will share too much personal information where it is inappropriate, will dominate conversations, and/or will send messages to others (via phone, or electronically) that are excessive in length and frequency.
By directly addressing the clients’ changes in manner of communication, therapists not only help them with a vital life skill, but they also assist them in self-assessing their communication as a tip-off about an impending symptom episode. Either way, the therapist’s efforts in helping clients with bipolar disorder to monitor, manage, and improve their communication repertoire and patterns is a highly important part of the CBT treatment plan.
References
Lam, D. H., Hayward, P., Watkins, E., Wright, K., & Sham, P. (2005). Relapse prevention in patients with bipolar disorder: Cognitive therapy outcome after two years. American Journal of Psychiatry, 162, 324-329.
Miklowitz, D. J. (2008). Bipolar disorder: A family-focused treatment. Guilford Press.
Newman, C. F., Leahy, R. L., Beck, A. T., Reilly-Harrington, N. A., & Gyulai, L. (2001). Bipolar disorder: A cognitive therapy approach. Washington, D.C.: American Psychological Association.
Perry, A., Tarrier, N., Morriss, R., McCarthy, E., & Limb, K. (1999). Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. British Medical Journal, 318, 139-153.
Scott, J., Paykel, E. M., Morriss, R., Bentall, R., Kinderman, P. J., Johnson, T., Hayhurst, H. (2006). Cognitive-behavioural therapy for severe and recurrent bipolar disorders: Randomised controlled trial. British Journal of Psychiatry, 188, 313-320.